Transcript Religion and Spirituality

RELIGION AND
SPIRITUALITY IN
MENTAL HEALTH
Angelic Chaison Ph.D., Houston
Daryl Fujii, Ph.D., Honolulu
Nancy Cha, Honolulu (intern)
and the
Multicultural & Diversity Committee (2010-2011)
VA Psychology Training Council
Contact persons:
Daryl Fujii Ph.D., Honolulu ([email protected])
Rachael Guerra Ph.D., Palo Alto
([email protected])
MULTICULTURAL/DIVERSITY
COMMITTEE
Committee 2010-2011
Loretta E. Braxton Ph.D., Durham (Co-Chair)
Linda R. Mona Ph.D., Long Beach (Co-Chair)
Angelic Chaison Ph.D., Houston
Daryl Fujii Ph.D., Honolulu
Rachael Guerra Ph.D., Palo Alto
Jamylah Jackson Ph.D., North Texas
Monica Roy Ph.D., Boston
Christina Watlington Ph.D., Perry Point
Miguel Ybarra Ph.D., San Antonio
Susana Blanco Ph.D., Bedford (Postdoc)
Nancy Cha, Honolulu (Intern)
Paul Lephuoc, Houston (Intern)
Katherine Hoerster Ph.D., Long Beach (Postdoc)
OVERVIEW
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Definitions
Learning objectives
Introduction
Empirical research on religion/spirituality
Conceptualizations of the role of
religion/spirituality in mental health
Clinical issues in which faith can become salient
Ethics
Assessment and therapy
Case examples and interactive activity
References
DEFINITIONS
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Religion usually refers to “beliefs, practices, and
rituals related to the sacred” (Koenig, 2009, p.284).
The term “sacred” often refers to objects or beings (i.e.
God, Allah) considered to be supernatural, holy, or
transcendent (Paragament, 1990).
 Religion can be organized and practiced within a
community that follows certain traditions and holds
certain beliefs (Koenig, 2009).
Spirituality is viewed as more personal and defined
by the individual. It is considered to be “largely free of
the rules, regulations, and responsibilities associated
with religion” (Koenig, 2009, p.284) and focuses on
aspects of life that are “transcendent” or larger than
the individual without necessarily having religious
overtones (Pargament, 1990).
LEARNING OBJECTIVES
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Participants will:
1.
Become familiar with literature on religion/spirituality
and mental health
2.
Learn multiple ways to conceptualize the role of
religion/spirituality in the lives of persons of faith
3.
Identify presenting issues for which religion/spirituality
can become salient
4.
Learn ways to incorporate religion/spirituality in
assessment and treatment
INTRODUCTION
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Results from the 2010 Gallup Poll indicate that at least 65% of
the U.S. population said that religion is important in their lives
(Gallup Poll, 2010).
The American Religious Identification Survey provides data
regarding ethnic representation among faiths in the US.
INTRODUCTION CONT.
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The nature of religion as it relates to psychology is a highly
debated topic and has been for a number of years.
Prominent psychologists such as Sigmund Freud, Albert
Ellis, and Carl Jung have often disagreed about whether
religion is helpful or harmful for people’s wellbeing.
Early empirical research yielded mixed results concerning
the impact of religiousness on mental health (e.g., Payne,
Bergin, Bielema, & Jenkins, 1991).
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Due to methodological limitations in early research, the
beneficial and potentially therapeutic aspects of clients’
religiousness was often overlooked (Richards, Smith & Davis,
1989).
INTRODUCTION CONT.
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Later research has demonstrated how individuals who draw on
a more deeply established system of religious beliefs, practices,
feelings, and relationships are in a good position to find
compelling religious solutions to various problems and cope
with everyday living (Pargament, 1997; Schaefer & Gorsuch,
1991).
At the same time, others have demonstrated how religion can
negatively impact coping during times of crises and can be
associated with poor mental health and event-related
outcomes (Pargament, 1997; Pargament, Zinnbauer, et al.,
1998).
Given that research has shown that religion/spirituality can
positively or negatively impact coping during times of crises, it
is important to understand the role of religion/spirituality on
mental health outcomes.
REVIEW OF EMPIRICAL RESEARCH ON
RELIGION IN MENTAL HEALTH
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In a review of studies examining the relation between
religion and mental health, Koenig (2009)
summarized that :
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Religion/spirituality is generally related to improved
coping and less depression, anxiety, suicide, and
substance abuse across different ethnic backgrounds,
age groups, settings and geographic locations.
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“Healthy normative religious beliefs and practices” may
be reassuring for people who experience psychosis with
religious delusions.
Koenig encouraged clinicians to be aware of the value
of religion as a resource for healthy mental and social
functioning and to recognize when religious beliefs
contribute to pathology.
REVIEW OF EMPIRICAL RESEARCH ON
RELIGION IN MENTAL HEALTH CONT.
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Koenig (2009) asserts that religious coping is
often found among patients with medical and
mental illness because faith:
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Provides a sense of meaning and purpose during
difficult transitions in life
Promotes hope and optimism
Provides role models for acceptance
Offers a sense of indirect control
Provides a community of support – human and divine
Is available at anytime regardless of financial, social,
physical or social circumstances
WAYS TO CONCEPTUALIZE
RELIGION AND SPIRITUALITY
CONCEPTUALIZATION OF RELIGION IN
MENTAL HEALTH
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With the development of the field of psychology of religion,
religion has become increasingly viewed as a multidimensional
construct that includes:
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Orientation towards their faith (e.g., religious orientation or
internalization)
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Application of their faith (e.g., religious coping)
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Interpersonal connectedness to others with similar faith
perspectives (e.g., religious social support)
Understanding how these aspects of religion impacts clients’
attributions of problems and preference for coping strategies can
assist in case conceptualization and identifying treatment
interventions.
ORIENTATION TOWARDS FAITH
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Religious Orientation (Allport & Ross 1967)
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Intrinsic Religious Orientation – describes individuals who
embrace their religious beliefs and find their “master motive” in
religion.
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Extrinsic Religious Orientation – describes individuals who use
religion for their own ends, including security, comfort, sociability,
and status.
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Generally associated with desirable variables, such as self-esteem
(Payne et al., 1991), personal adjustment (Bergin, Masters, &
Richards, 1987), etc.
Generally associated with prejudice (Allport & Ross, 1967), trait
anxiety (Peterson & Roy, 1985), personal distress, (Genia, 1996),
and sexual permissiveness (Haerich, 1992)
A meta-analytical review showed that intrinsic and extrinsic religious
orientations are associated with lower and higher levels of
depression, respectively (Smith, McCullough, & Poll, 2003)
ORIENTATION TOWARDS FAITH CONT.
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Religious Internalization (Ryan, Rigby, & King, 1993)
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Identified Religious Internalization – when religious
practices are experienced as personally valuable and are
performed voluntarily because individuals see these
practices as self-initiated.
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Positively associated with measures of psychological adjustment,
and negatively associated with depression, anxiety, and
somatization (Ryan, et. al, 1993)
Introjected Religious Internalization – when religious
practices are performed because not performing the behavior
could bring about guilt, anxiety, and loss of esteem.
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Positively related to anxiety, depression and somatization and
negatively related to psychological adjustment measures (Ryan, et.
al, 1993)
APPLICATION OF FAITH
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Religious attributions (Pargament, 1990)
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Religious problem-solving styles (Pargament,
Kennell, Hathaway, Grevengoed, Newman, & Jones, 1988).
 Self-directive
Deferring
 Collaborative
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Positive and negative religious coping (Pargament,
Smith, et al. (1998)
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Spiritual surrender (Cole & Pargament, 1999)
SOCIAL CONNECTEDNESS IN RELIGIOUS
COMMUNITIES
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Research (Baetz & Toews, 2009; Pargament, 1990)
has shown that social support in religious
communities can be experienced as helpful when
support:
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Meets the psychological need of belongingness
Provides material resources (e.g., housing, food, etc.)
Offers helpful coping suggestions
Social support in religious communities can be
experienced as harmful when individuals perceive
members of religious communities as (Baetz & Toews,
2009; Pargament, Zinnbauer, et al.,1998):
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Unavailable or uncaring
Critical and judgmental
CLINICAL ISSUES IN WHICH
FAITH BECOMES SALIENT: PTSD
PTSD AND RELIGION/SPIRITUALITY
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PTSD and Religious Faith
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“One of the most pervasive effects of traumatic exposure is
the challenge that people experience to their existential
beliefs concerning the meaning and purpose of life.” (Fontana
& Rosenheck, 2004).
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Traumatic exposure often has a weakening effect on religious
faith (e.g. Calhoun and Tedeschi, 1999; Decker, 1993; JanoffBulman, 1992; Liefton, 1988).
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Traumatic exposure also has a strengthening effect on
religious faith (Calhoun et al., 2000; Drescher and Foy, 1995;
Lawson et al., 1998; Racklin, 1998)
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Strength of religious faith has an inverse association to
severity of PTSD symptoms (e.g. Astin et al., 1993; Davis et
al., 1998; Klingler, 1999; Murad, 1991; Phan and Kingree,
2001; Saunders, 1999)
PTSD and Religion/Spirituality
PTSD,
Religious Faith and Mental Health Service
Veteran’s
pursuit of mental health services
appears to be driven more by their guilt and the
weakening of their religious faith than by the
severity of their PTSD symptoms or their deficits in
social functioning (Fontana & Rosenheck, 2004).
Raises the broader issue of whether spirituality
should be more central to the treatment of PTSD,
either in the form of a greater role for pastoral
counseling or of a wider inclusion of spiritual issues
in traditional psychotherapy for PTSD.
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PTSD and Religion/Spirituality
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Guilt and Mental Health
 Trauma related guilt in the war-zone (Kulbany et
al. 1997)
PTSD,
Forgiveness and Religious Coping
 Witvliet, Phipps, Feldman & Beckham (2004)
found significant associations between difficulty
forgiving others, difficulty forgiving oneself, and
negative religious coping (e.g., appraisal of the
problem as God’s punishment, interpersonal
religious discontent) with difficulties in mental
health for veterans with PTSD.
CLINICAL ISSUES IN WHICH
FAITH BECOMES SALIENT:
SEXUAL ORIENTATION
CONFLICT BETWEEN RELIGION AND NONHETEROSEXUAL ORIENTATIONS
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Mainline Protestant, Catholic, Islamic, Judaism prohibit
homosexuality
Social implications for negative attitudes:
LGB participate in organized religion less than heterosexuals
– Participation can be detrimental to psychological health
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Implications for GLB individuals
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Struggle in integrating sexual identity with religious faith
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LGB individuals can abandon their faith in securing a LGB identity
LGB individuals also feel their faith has abandoned them
Development of internalized homo-negativity
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Associated with shame, depression, suicidal ideation, psychological
distress, low self-esteem, lack of perceived social support, and difficulty
accepting LGB identity,
(review Lease, Horne, Noffsinger-Frazier, 2005)
INTERVENTIONS
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Help GLB individuals developing own personal
spirituality associated with greater psychological
health
Help clients separate non-affirming doctrine with
faith practices and principles that support the
goodness in all people
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Replace redemption and sin model with one that
celebrates all creation
Encourage involvement in LGB-affirming faiths
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Faiths evolved by altering traditional doctrine to be
more inclusive or developing own doctrines
CLINICAL ISSUES IN WHICH
FAITH BECOMES SALIENT:
RELIGION AND END OF LIFE BELIEFS AND PRACTICES
ISLAM (HENDI, 2011)
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Muslims believe in an afterlife
Illnesses are part of life and not punishment
for sins
Cures should be sought, but only God grants cures
Those who endure illness with patience will be
rewarded at time of judgment
– It is okay to complain of pain as long as the person
does not blame God
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Euthanasia or attempts to shorten life are
prohibited
If person done wrong to someone, forgiveness
should be sought as the rights of man are
more important than the rights of God
Islamic creed should be recited at moment of
death
BUDDHISM (KRAMER, 2011)
Buddhists believe in karma and reincarnation; a
person will be reborn until one achieves
enlightenment.
 Clarity of mind is important at time of death as it can
profoundly affect state of next rebirth. Thus clinicians
should:
 Encourage patient to express love and kindness to
others
 Encourage reflection and rejoicing in virtuous
activities
 Past regrets can be addressed by asking forgiveness,
making amends, or confessing to a spiritual leader
 Facilitate a peaceful and calm environment
 Avoid excessive medications that can cloud
consciousness
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JUDAISM (KINZBRUNNER, 2011)
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Judaism is focused on life and how to live it versus how to get into
heaven. Judaism believes in an afterlife but has little dogma
about it.
After death, a person’s soul is purified/punished by fire in Gehinnom
(maximum of 12 months, time contingent upon amount of sin). The soul
eventually ends up in Gan Eden (heaven)
 All souls are eventually resurrected during Olam Ha-Ba “World to Come“
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Jewish beliefs and End Of Life (EOL) care:
Euthanasia and forms of intentionally hastening death is prohibited
 For more conservative Jews, food and fluid even when provided artificially are
considered basic care
 For Orthodox Jews, the Rabbi must be included as a named surrogate to
ensure decision –making is made in accordance to Jewish law
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Jewish rituals and EOL care:
Many different prayers (e.g. Mi'sheberachprayer for sick; Vidui,a confession)
 Many restrictions (e.g. only Kosher foods eaten, prohibition of inter-gender
contact/care providers, rituals for cleansing of body at time of death )
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CHRISTIANITY (NICHOLS, 2011, PICCHI, 2011)
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Christians are highly heterogeneous in interpretation of the Bible,
worship practices, and beliefs about the afterlife and salvation
The key is asking the right questions
Christians generally believe in an eternal afterlife involving either
heaven and hell
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Heaven is generally perceived as being with God, while beliefs about
hell range from a place of eternal torture to an eternity without God
Beliefs about how one is selected to go to heaven vary widely
Catholics believe salvation is achieved through repentance made to a
priest
 Many Protestant sects believe salvation is achieved through direct
prayers to God
 Some sects believe that persons are preselected
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EOL concerns often pertain to personal salvation
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For examples, Catholics believe it is a time for Reconciliation:
attending to unfinished business, seeking amends, restoring a right
relationship with oneself, others, and God
Prayers, Reading scriptures, and visits by clergy are general
interventions for Christians
ETHICS, ASSESSMENT, AND
TREATMENT
ETHICS
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Baetz & Toews (2009) review multiple positions
regarding incorporating religion/spirituality in
clinical settings.
 For
Using a biopsychosocial-spiritual model meets
patients desire to be asked about their spiritual
commitments and concerns
 A preponderance of research supports the potential
health benefits of religion/spirituality for clients who
are religiously-inclined.
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Against
 Religion is a private matter not to be discussed with
health professionals
 The power differential between provider and patient
may appear as coercion.
ASSESSMENT
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Clinical Interview – acronyms have been created to
assist in assessing for clients’ spirituality in the
psychosocial history
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FICA (Puchalski & Romer, 2000)
Do you have Faith or believe?
 Importance in clinical care?
 Are you part of a faith Community?
 Is there a way you would like it to be Addressed as part of
care?
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HOPE (Anandarajah & Hight, 2001)
Source of Hope or meaning
 Organized religion
 Personal spirituality or Practices
 Effect on medical care and/or End of Life
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ASSESSMENT
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Measures
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Religious Orientation Scale (Allport & Ross 1967;
Genia, 1993; Gorsuch & McPherson, 1989)
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Christian Religious Internalization Scale (Ryan,
Rigby, & King)
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Religious Problem-Solving Styles (Pargament, et al.
1988)
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Positive and Negative Religious Coping (Pargament,
Smith, et al., 1998)
THERAPY
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Establish of a collaborative relationship that provides a
safe context to explore religious concerns (Miller &
Thorensen, 1999)
Consult with religious leaders/clergy and coordinate
care as appropriate (Miller & Thorensen, 1999)
Baetz & Toews (2009) reviewed ways
religion/spirituality can be incorporated in treatment:
Attributions for life events
 Reframing of problems as spiritual opportunities
 Religious behaviors that contribute to self-regulation and selfcalming
 Religious coping that promotes forgiveness, gratitude,
compassion, and altruism
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CASE EXAMPLES AND
INTERACTIVE ACTIVITY
CASE EXAMPLE: PRESENTING PROBLEM
JS is a 41 year-old Latino male who had his first
psychotic break while serving in the Marine Corps. He
is married with a 6 year-old son. Just before his son
was born, JS attempted suicide by jumping off a bridge.
He sustained a brain and spinal cord injury, the latter
resulting in paraplegia. JS was hopeful to walk during
his first 2 years in inpatient rehab, but was transferred
to a long term care facility after it was determined that
he would not walk again. JS became depressed. About
a year later, JS reported hearing God saying "sky" to
him from the bathroom which he interpreted as God
wanting him to be with him. JS became obsessed with
dying and going to heaven and constantly begged the
doctors to kill him.
CLINICIAN INTERVENTION
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Knowing JS was a Catholic, psychologist KM
asked him what Catholics believed about death
and suicide. JS knew that suicide was not right,
but rationalized that God wanted him in heaven.
KM stated that if God wanted him to die, he
would have died in the fall. The fact that he is
alive must mean that God had a plan for him. JS
agreed, however, due to cognitive deficits,
including memory and executive problems, it
took about a month before his conversation with
KM stuck with him. KM then worked with JS to
find meaning in his life which focused on being a
good father to his son and helping others.
CASE EXAMPLE: PRESENTING PROBLEM
Dana (aged 31 years) was a Christian female who
presented to psychotherapy with several symptoms of
depression. As psychotherapy progressed, Dana
explored negative beliefs about herself. Her most
problematic core belief was that she was worthless and
no one would ever love and accept her as she was.
These beliefs seemed related to childhood physical
abuse by her mother, who eventually abandoned her.
Dana was a committed Christian. At intake she asked to
incorporate issues of R/S in her psychotherapy.
Case example with therapy interventions comes from Worthington,
Hook, Davis, & McDaniel (2011)
CLINICIAN INTERVENTION
The cognitive model of depression emphasizes the role of
maladaptive cognition in causes and treatment (Beck, Rush, Shaw,
& Emery, 1979). Christian-accommodative cognitive therapy for
depression retains the features of the secular theory, yet places the
psychotherapy in a religious context. For example, the rationale for
psychotherapy, the homework assignments, the challenging of
negative automatic thoughts, and core beliefs are integrated with
and based on biblical teachings regarding the self, world, and future
(Pecheur & Edwards, 1984).
As Dana and her therapist explored and modified her negative core
beliefs, they discussed how Dana thought God viewed her. Several
passages of the Bible comforted Dana and helped her realize that
although she viewed herself negatively, God and other people
loved and accepted her as she was.
CASE EXAMPLE: PRESENTING PROBLEM
Dave (aged 47 years) did not profess a religion.
He considered himself to be spiritual. After he lost
his job because he failed a drug test, he checked
into a rehabilitation facility. He had
been dependent on drugs and alcohol on and off
for 30 years.
Case example with therapy interventions comes from Worthington,
Hook, Davis, & McDaniel (2011)
CLINICAL INTERVENTION
Spiritual self-schema therapy integrates cognitive-behavioral techniques with
Buddhist psychological principles (Avants & Margolin, 2004). The goal of this
psychotherapy is to modify a person’s self-schema. When a self-schema is
activated, beliefs about the self energize specific behaviors. This
psychotherapy attempts to facilitate a shift from an ‘‘addict’’ self schema to a
‘‘spiritual’’ self-schema that fosters mindfulness, compassion, and doing no
harm to self or others (Margolin et al., 2007). Psychotherapy sessions focus
on aspects of the Buddhist Noble Eightfold Path, which include training in
mindfulness, morality, and wisdom.
During psychotherapy, Dave was taught about the wandering nature of
the mind and how this contributed to his addict self-schema. When Dave
did not work to control his mind, he thought of using drugs. He practiced
a meditation technique called anapanasati, which involved sitting silently
with eyes closed and focusing on the sensations experienced while
breathing naturally. Dave improved his concentration and mindfulness
with practice and began to discipline his maladaptive thoughts.
INTERACTIVE ACTIVITY
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Case discussion is often a helpful way to identify
ways to proceed with challenging cases. Now that
you have discussed the case examples included in
this presentation, take a moment to reflect on
one of your past or current cases that involved
religion/spirituality.
Discuss various ways to approach the case in
light of the information discussed during this
presentation.
REFERENCES
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Allport, G.W., & Ross, J.M. (1967). Personal religious orientation and prejudice.
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